Provider Demographics
NPI:1891716502
Name:LEE, KEAT-JIN (MD)
Entity Type:Individual
Prefix:
First Name:KEAT-JIN
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LONG WHARF DR
Mailing Address - Street 2:SUITE 302
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-5991
Mailing Address - Country:US
Mailing Address - Phone:203-777-4005
Mailing Address - Fax:203-776-7741
Practice Address - Street 1:1 LONG WHARF DR
Practice Address - Street 2:SUITE 302
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-5991
Practice Address - Country:US
Practice Address - Phone:203-777-4005
Practice Address - Fax:203-776-7741
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT015233207Y00000X, 207YX0602X, 207YX0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
No207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001152339Medicaid
CT041069592OtherRAILROAD MEDICARE PIN
CT041069592OtherRAILROAD MEDICARE PIN
CT040000100Medicare ID - Type Unspecified